Every finding on record at Avenues at Litchfield

Based on interview and record review the facility failed to prevent resident to resident abuse for 2 (R3, R4) residents reviewed for abuse in the sample of 3. Findings include: R3's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnoses including schizophrenia and anxiety. R3's Quarterly Minimum Data Set (MDS) dated , 1/14/2026 documents R3 is cognitively intact and physical behavioral symptoms not directed towards others occurred daily. R3's Nursing Note, dated 2/12/2026 at 5:13 PM documents reported to me by V6, Activity Director that R4's roommate was yelling and cussing, he then slapped R3 in the face, when I went to room R3 was laying on his bed quietly and his roommate (R4) was still angry. (R4) was sent to the ER (Emergency Room) for eval (evaluation.)On 5/19/2026 at 1:40 PM R3 stated a few months ago his roommate (R4) slapped him across the face out of the blue and he was upset about it because he didn't know why he slapped him. R3 stated they are no longer roommates, and he hasn't had any further issues with R4. R4's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, anxiety and depression. R4's Quarterly Minimum Data Set (MDS) dated , 1/26/2026 documents R4 is cognitively intact and physical behavioral symptoms not directed towards others occurred 4 to 6 days. R4's Nursing Note, dated 2/12/2026 at 4:41 PM documents activities reported to me that this resident was being physically aggressive to his roommate, went to room and 1:1 with this resident, he was laying in bed, he was angry and agitated stated he was tired of listening to his roommate's damn radio/Christian music, he is tired of being held prisoner here and he wants out. Unable to redirect, he and his roommate were separated, and he was sent to local hospital ER/emergency room for eval/evaluation and psych updated. On 5/19/2026 at 1:30 PM R4 stated he slapped his old roommate (R3) silly one day because he wouldn't turn down his music and it was driving him crazy. R4 stated staff came into the room immediately after he slapped him and separated them and they aren't roommates anymore and they haven't had any other issues since then. On 5/19/2026 at 12:30 PM V6, Activity Director stated she heard men yelling from her office and on her way to R3's and R4's room she heard what sounded like a loud slap and R3 yelled stop hitting me. V6 stated when she entered the residents' room she witnessed R4 standing over R3 and R4 was yelling at R3 to turn down his music. V6 stated she separated R3 and R4 immediately and reported the altercation to V1 Administrator, V2 Director of Nurses (DON) and the assigned nurse (name unknown.) On 5/19/2026 at 3:00 PM V1, Administrator, stated she is the facility's abuse coordinator, and she substantiated the resident-to-resident physical abuse allegation between R3 and R4 because after interviewing both residents R3 reported that R4 slapped him across the face and R4 admitted to slapping R3. On 5/20/2026 at 8:20 AM V2, Director of Nurses, stated she was at the facility when V6 reported there was a verbal and physical resident to resident altercation between R3 and R4 on 2/12/2026 and she immediately went and assessed both residents including a psychosocial assessment and neither resident was upset or crying regarding the altercation. The Initial and Final Abuse Investigation Report dated 2/12/2026 and 2/19/2026 documents on 2/12/2026 at approximately 12:20 PM, an allegation of a physical altercation between R3 and R4 was reported to the nurse. Residents were immediately separated. R3 and R4 were assessed for psychosocial and physical injuries with none note. Investigation initiated including resident and staff interviews. Employees and residents were interviewed by V1. R3 was interviewed and voiced he was in his room resting and listening to music when his roommate, R4, started yelling at him. R4 then made contact to R3's face with an open hand. V6 intervened and separated the residents, bringing R3 to her office. R4 was interviewed and stated R3 was continuously listening to music, and he just wanted it off. V6 was interviewed and stated R4 was yelling at his roommate, R3 and she went to intervene, separated the residents and notified the nurse. Nurse assessed both residents and V6 notified V2 and V1 of event. Conclusion and Action Taken: Based on the investigation R3 was in his room resting when roommate R4 became angry and started yelling and made open hand contact to R3's face. Staff intervened and separated residents, then notified nurses.The Abuse Prevention and Reporting - Illinois Policy, last revised 3/2026 documents the facility affirms the right of our residents to be free from abuse. This facility therefore prohibits abuse of residents.

Based on interview and record review the facility failed to follow the facility policy and prevent resident to resident abuse for 2 (R3, R4) residents reviewed for abuse in the sample of 3.Findings include: R3's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnoses including schizophrenia and anxiety. R3's Quarterly Minimum Data Set (MDS) dated , 1/14/2026 documents R3 is cognitively intact and physical behavioral symptoms not directed towards others occurred daily. R3's Nursing Note, dated 2/12/2026 at 5:13 PM documents reported to me by V6, Activity Director that R4's roommate was yelling and cussing, he then slapped R3 in the face, when I went to room R3 was laying on his bed quietly and his roommate (R4) was still angry. (R4) was sent to the ER (Emergency Room) for eval (evaluation.)On 5/19/2026 at 1:40 PM R3 stated a few months ago his roommate (R4) slapped him across the face out of the blue and he was upset about it because he didn't know why he slapped him. R3 stated they are no longer roommates, and he hasn't had any further issues with R4. R4's Undated Face Sheet documents he was initially admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, anxiety and depression. R4's Quarterly Minimum Data Set (MDS) dated , 1/26/2026 documents R4 is cognitively intact and physical behavioral symptoms not directed towards others occurred 4 to 6 days. R4's Nursing Note, dated 2/12/2026 at 4:41 PM documents activities reported to me that this resident was being physically aggressive to his roommate, went to room and 1:1 with this resident, he was laying in bed, he was angry and agitated stated he was tired of listening to his roommate's damn radio/Christian music, he is tired of being held prisoner here and he wants out. Unable to redirect, he and his roommate were separated, and he was sent to local hospital ER for eval and psych updated. On 5/19/2026 at 1:30 PM R4 stated he slapped his old roommate (R3) silly one day because he wouldn't turn down his music and it was driving him crazy. R4 stated staff came into the room immediately after he slapped him and separated them and they aren't roommates anymore and they haven't had any other issues since then. On 5/19/2026 at 12:30 PM V6, Activity Director stated she heard men yelling from her office and on her way to R3's and R4's room she heard what sounded like a loud slap and R3 yelled stop hitting me. V6 stated when she entered the residents' room she witnessed R4 standing over R3 and R4 was yelling at R3 to turn down his music. V6 stated she separated R3 and R4 immediately and reported the altercation to V1 Administrator, V2 Director of Nurses (DON) and the assigned nurse (name unknown.) On 5/19/2026 at 3:00 PM V1 stated she is the facility's abuse coordinator, and she substantiated the resident-to-resident physical abuse allegation between R3 and R4 because after interviewing both residents R3 reported that R4 slapped him across the face and R4 admitted to slapping R3. On 5/20/2026 at 8:20 AM V2 stated she was at the facility when V6 reported there was a verbal and physical resident to resident altercation between R3 and R4 on 2/12/2026 and she immediately went and assessed both residents including a psychosocial assessment and neither resident was upset or crying regarding the altercation. The Initial and Final Abuse Investigation Report dated 2/12/2026 and 2/19/2026 documents on 2/12/2026 at approximately 12:20 PM, an allegation of a physical altercation between R3 and R4 was reported to the nurse. Residents were immediately separated. R3 and R4 were assessed for psychosocial and physical injuries with none note. Investigation initiated including resident and staff interviews. Employees and residents were interviewed by V1. R3 was interviewed and voiced he was in his room resting and listening to music when his roommate, R4, started yelling at him. R4 then made contact to R3's face with an open hand. V6 intervened and separated the residents, bringing R3 to her office. R4 was interviewed and stated R3 was continuously listening to music, and he just wanted it off. V6 was interviewed and stated R4 was yelling at his roommate, R3 and she went to intervene, separated the residents and notified the nurse. Nurse assessed both residents and V6 notified V2 and V1 of event. Conclusion and Action Taken: Based on the investigation R3 was in his room resting when roommate R4 became angry and started yelling and made open hand contact to R3's face. Staff intervened and separated residents, then notified nurses.The Abuse Prevention and Reporting - Illinois Policy, last revised 3/2026 documents the facility affirms the right of our residents to be free from abuse. This facility therefore prohibits abuse of residents. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse of residents. Physical abuse is defined as the infliction on a resident which includes hitting and slapping.

Based on interview and record review, the Facility failed to ensure a Registered Nurse (RN) was working at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 62 residents living in the facility. Findings includes: The facility's partial August 2024 Daily assignment sheets for 8/30/2024 and 8/31/2024, documented that there was not consecutive 8 hours of consecutive RN coverage. The facility's September 2024's RN staffing documented that there was not consecutive 8 hours of consecutive RN coverage on 9/9/24, 9/10/24, 9/11/24, 9/13/24, 9/14/24, 9/15/24, 9/17/24, 9/18/24, 9/19/24, 9/23/24, 9/24/24, 9/25/24, 9/27/24, 9/28/24, 9/29/24. On 09/30/2024 at 4:00PM, V2, Director of Nurses, stated that she was told by her corporate nurse that as long as it was a consecutive 8 hours then her night RN would count as the RN. V2 stated that that RN works 10 pm to 6 am and that the new day starts at 12:00 AM. V2 continued to state that she guessed then the new day would start at 12 am and that only 6 of the 8 hours would be on the new day. On 10/02/204 at 3:10 pm, V1, Administrator, stated that they do not have a RN Coverage policy and that they follow CMS (Center for Medicare and Medicaid Services) guidelines. The Facility's Long Term Care application for Medicare and Medicaid, CMS 671, dated 9/30/2024 documented that the facility had a census of 62 residents.

Based on observation, interview and record review, the facility failed to ensure food was at the proper holding temperature at the steam table for 4 of 12 residents (R8, R21, R23, R35) reviewed for food temperatures in the sample of 62. Findings include: On 10/1/2024 at 11:55 PM, during the lunch service R8 was served mechanical hot dog meat and tater tots. On 10/1/2024 at 11:56 PM, R35's meal ticket documented a mechanical diet. On 10/1/2024 at 11:58 AM, during the lunch service R35 was served a mechanical hot dog meat on a bun. On 10/1/2024 at 11:59 AM, during the lunch service R21 was served a mechanical hot dog meat on a bun and tater tots. On 10/1/2024 at 12:00 PM, R21's dietary ticket documents he was on a mechanical diet. On 10/1/2024 at 12:03 PM, during the lunch service R23 was served a mechanical hot dog meat on a bun and tater tots. On 10/1/2024 at 12:04 PM, R23's dietary ticket documents he was on a mechanical diet. On 10/01/2024 at 12:12 AM, after the last lunch plate had been served, food temperatures were taken on the steam table with a calibrated metal thermometer and the following temperatures were below 135 degrees Fahrenheit (F), tater tots 130.0 F, and the mechanical hot dog meat was at 112.0 F. On 10/1/2024 at 1:11 PM, V11, Dietary Manager provided a list of male residents who were on mechanical meat and the following residents were documented as being on mechanical meat R8, R21, R23, and R25. On 10/1/2024 at 1:14 PM, V11 stated we feed the male residents first at 11:30 AM, and then after they leave the dining room then we feed the female residents. On 10/1/2024 at 1:20 PM, the Food temperature book did not record any temperatures for the first lunch service. The areas were blank. On 10/1/2024 at 1:22 PM, V12, cook stated, I took the temperatures but I did not record them in the book. I have the temperatures somewhere around here. On 10/1/2024 at 4:01 PM, V11 stated, I would expect all the food on the steam table to be at least 165 degrees or higher when holding. I heard that when you took temperatures today, they were below 112.0 F and I know that is. I am in the middle of my training for my certification for the dietary manager. On 10/1/2024 at 4:11 PM, V14, Dietician stated, I would expect all items on the steam table to be held at 135 degrees Fahrenheit or higher. If the temperature is less than 135 degrees, bacteria can grow if the temperature is between 41-135 degrees F, which could lead to food borne illness. The Monitoring Food Temperatures for Meal Service Policy dated 2020 documents, Food temperatures will be monitored to prevent foodborne illness and ensure foods are served at palatable temperatures. The temperature for each food item will be recorded on the Food Temperature Log. Foods that required a corrective action (such as reheating); will have the new temperature recorded with a notation of the corrective action intervention. If the serving/holding temperature of a hot food item is not at 135 F or higher (check your state specific regulations: some states require 140 F minimum hot holding temperature) when checked prior to meal service, the item will be reheated to at least 165 F for a minimum of 15 seconds. The item may be reheated only once and must be discarded or consumed within two hours. Any reheated item that is left after meal service or held longer than two hours is discarded.

Based on interview and record review, the Facility failed to ensure residents were receiving the lowest effective doses, recommended by licensed pharmacists, in a timely fashion for 2 of 5 residents (R14, R38) reviewed for unnecessary medications, in the sample of 62. Findings include: 1. On 9/30/2024 at 9:30 AM, R14 stated, They give me a shot of something in the morning. R14's Face sheet dated 10/3/2024 documents, Long term (current) use of insulin. Consultant Pharmacist Recommendation to Nursing dated 8/23/2024 documents, Medication reduction request- Resident is on the following diabetic medications: Metformin ER (Extended Release) 500 mg (Milligrams) 1 tablet in the morning and 2 tablets at bedtime, Basaglar 40 units once daily, and Fiasp 10 units with meals. Recent blood glucose monitoring low. 8/23/2024 54 (normal 70-100). Most recent A1C (Hemoglobin A1C levels indicate the percentage of hemoglobin coated with glucose) 6-2024 (June 20224) 4.5 (Normal: Less than 5.7%). Recommend further reduction of basaglar to 35 units once daily. R14's Physicians Orders dated 10/3/2024 documents, Basaglar (insulin)- inject 40 units subcutaneous in the morning. R14's Care Plan documents, Diabetes Mellitus- (R14) will have no complications related to diabetes through the review dated (12/18/2024). Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. R14's Progress Notes dated 10/2/2024 documents, Updated doctor office on blood sugars. On 10/3/2024 at 9:06 AM, V2, Director of Nursing (DON) stated, On 8/23/2024 the pharmacist recommended (R14's) insulin to be decreased by 5 units. It has not been addressed by the doctor. I had the nurse send the blood sugars to the doctor for review. He also has an appointment to be seen (by the doctor related to his blood sugars). R14's Weights and Vitals Summary documents R14's blood sugar level was low on 9/23/2024 at 57 (normal range is 70-100). 2. R38's Care Plan dated 1/2/2023 documents R38 has the potential for fluid deficient related to diuretic use. Administer medications as ordered. Monitor/document for side effects and effectiveness. R38's Consultant Pharmacist Recommendation to MD (Medical Doctor) dated 6/26/2024 documents, Resident had recent labs with an increased in creatinine from 1.6 to 3.1. Please Evaluate resident and determine if furosemide (diuretic) and or lisinopril dose needs adjusted. It continues to document, Agree- decrease furosemide from 60 mg BID (twice a day) to 60 mg in the AM and 40 mg in the PM. R38's Lab Results Report dated 6/20/2024 documents R38's creatinine level was 3.1 (Reference range 0.7-1.3). R38's Lab Results Report dated 7/2/2024 documents R38's creatinine level was 2 (Reference range 0.7-1.3). R38's Physician's Orders dated 8/2/2024 documents, Lasix- Give 40 mg by mouth in the evening and Lasix- give 60 mg by mouth in the morning for hypertension. R38's Lab Results Report dated 10/2/2024 documents R38's creatinine level was 1.9 (Reference range 0.7-1.3). R38's Weights and Vital Sign Summary documents R38's blood pressure was 97/51 on 8/6/2024 (normal range is 120/80). R38's Weights and Vital Sign Summary documents R38's blood pressure was 94/52 on 8/7/2024. R38's Weights and Vital Sign Summary documents R38's blood pressure was 96/63 on 9/22/2024. On 10/1/2024 at 3:15 PM, V2 stated, We have had a delay in getting the GDRs (Gradual Dose Reductions) addressed. The nurse who was doing them is no longer with our doctor (medical director). (V17, Nurse Practitioner) came and handed me the paper dated 7/11(2024). I made her cross it out and put 8/2/2024. I can't process it (the recommendation) if I don't have it. On 10/3/2024 at 10:08 AM, V18, Licensed Practical Nurse (LPN) stated, When they do them (pharmacy recommendations/monthly medication reviews) they send them to (V2). I don't know how long it takes for her to get them back. Our nurse practitioner (V17) comes every week. On 10/3/2024 at 12:11 PM, V2 stated she should have followed up within a couple days of not receiving orders on the recommendations. The Facility's Pharmacist Medication Regimen Review Policy, Effective: 11/2023, documents, Guidelines: The Consultant Pharmacist shall provide pharmaceutical care consultation including the medication regimen review at least once per calendar month for each resident in certified areas of a skilled long term care facility. For residents residing in long term care facilities licensed for the developmentally disabled or assisted living, pharmaceutical care consultation including medication regimen review will be conducted in compliance with state regulation. Procedure: 1. The Consultant Pharmacist will review the medication regimen of each resident in sufficient detail to determine if any apparent irregularities (defined by CMS as the use of medication that is inconsistent with accepted standards of practice for providing pharmaceutical services, not supported by medical evidence, and/or that impedes or interferes with achieving the intended outcomes of pharmaceutical services), exist. Federally mandated standards of care as well as other applicable standards serve as the basis for review to ensure that a resident's medications are promoting or maintaining the resident's highest level of function in congruence with the resident's therapeutic goals and to identify clinically significant risks and/or adverse medication reactions. 2. The review of the medication regimen will include all medications currently ordered, including medications that are ordered on a PRN or as needed basis. The review will incorporate information from the resident's chart concerning the resident's condition, monitoring for side effects, potential for drug-drug interactions, psychotropic medication review including considerations for dose reduction/optimal dosing, review for potentially unnecessary medication usage, as well as review of the medication administration records and ancillary documentation such as the physician's progress notes, nursing notes and laboratory test results. 3. The Consultant Pharmacist will report any irregularities in writing to the attending physician, the Medical Director and the Director of Nursing for follow up. The written documentation will include, minimally, the resident's name, the relevant drug and the identified irregularity. The Consultant Pharmacist will communicate any irregularities that require URGENT action directly to the Director of Nursing or other designated clinical staff for immediate resolution. The Director of Nursing or designee will notify the attending physician of recommendations either in person, by telephone, fax or other secure system of notification within 3 business days of receiving report from the Consultant Pharmacist. If no response is received from the attending physician within 3 business days following notification, the Director of Nursing will make a second attempt to notify the attending physician. If the attending physician does not respond after a second attempt, the Medical Director will be notified of recommendation.

Based on observation, and interview the facility failed to provide 80 square feet of floor space per resident bed for 58 of 62 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R13, R14, R15, R16, R17, R18, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R41, R42, R43, R44, R45, R46, R47, R48, R49, R50, R51, R52, R53, R54, R55, R56, R57, R58, R59, R60, R61 and R62) reviewed for room size requirements in the sample of 62. Findings include: On 10/01/2024 at 3:19 PM, V1, Administrator, stated there have not been any changes to any of the rooms since the last survey and she has a waiver for these rooms because they are less than 80 square feet. The facility has 33 two bed resident rooms that can be occupied by 2 residents. According to historical data, the room measurements for these rooms provide 76 square feet per bed. All rooms are certified for Medicaid. On 10/1/2024 at 2:42 PM, R1, R3, R4, R6, R7, R9, R10 R11, R15, R17, R22, R27, R34, R36, R37, R39, R41, R43, R44, R46, R48, R49, R50, R51, R53, R56, R58 and R59 all reside on A hall and all of these beds are Medicaid certified and provide 75 square feet per bed. On 10/1/2024 at 2:45 pm, R2, R5, R8, R13, R14, R16, R18, R21, R23, R24, R25, R26, R28, R29, R30, R31, R32, R33, R35, R38, R42, R45, R47, R52, R54, R55, R57, R60, R61, and R62 were all residing on the B hall, all beds are Medicaid certified and provide 75 square feet per bed. Observations made throughout the survey from 9/30/2024 to 10/1/2024 demonstrate no concerns or complaints vocalized by residents in relation to waivered room size. On 10/2/2024 at 2:35 PM, V1 stated they did not have a policy on room measurements.

Based on interview and record review the Facility failed to ensure a Registered Nurse (RN) was working at least 8 consecutive hours a day, 7 days a week. This has the potential to affect all 62 residents living in the facility. Findings include: On 09/17/2023 at 9:55 AM, V1, Administrator stated we are not having any issues with RN coverage. We have a RN working every day. On 9/17/2023 at 10:15 AM, V4, Licensed Practical Nurse (LPN) stated We did not have a RN working on Saturday because she had a wedding to go to. We were without a RN that night. Staffing schedules were reviewed from 8/25/2023 to 9/17/2023 and no RN was documented as working on Saturday, 9/16/2023. On 9/17/2023 at 9:57 AM, V1 stated We did have a RN call off on 9/16/2023 and we did not have a RN working that day. I realize the regulations require a RN to work 8 consecutive hours, seven days a week. On 9/17/2023 at 10:30 AM, V2, Director of Nursing stated, The RN called off on 9/16/2023 but normally we have a RN working every day for 8 consecutive hours. The Facility assessment dated [DATE] documents, the total of licensed beds was 65, with average census of 62. The staffing plan documents, Based on your resident population and their needs for care and support, describing your general approach to staffing to ensure that you have sufficient staff to meet the needs of the residents at any given time. Licensed Nurses (LN): RN, LPN providing direct care. Day shift 2, evening shift 2 and night shift 1. The Facility's Resident Census and Conditions of Residents form, CMS 672, dated 9/17/2023 documented the facility had a census of 62 residents.

Based on interview and record review, the facility failed to obtain lab draws as ordered by the physician for monitoring therapeutic drug levels for 1 of 7 residents (R11) reviewed for unnecessary medications in the sample of 64. Findings include: R11's Face Sheet documents her diagnoses to include Post Traumatic Seizures and Personal History of Traumatic Brain Injury. R11's Physician Order Summary dated 9/19/23 documents the following orders: 8/31/23: Trileptal Oral Tablet 300 milligrams (mg) (Oxcarbazepine) Give 1 tablet by mouth in the evening related to Post Traumatic Seizures. Give with 150 mg tab to equal 450 mg daily. 8/31/23: Levetiracetam Oral Tablet 1000 mg (Levetiracetam) Give 1 tablet by mouth two times a day related to Post Traumatic Seizures; Personal History of Traumatic Brain Injury. 12/13/22: CBC (Complete Blood Count), B12, CMP (Complete Metabolic Profile), TSH (Thyroid Stimulating Hormone Level), VITAMIN D LEVEL, HGBA1C (Hemoglobin A1C), Trileptal and Keppra (Levetiracetam) level every 6 months-April/October. R11's Electronic Medical Record documents, under lab and x-ray results, that no B12, TSH, Vitamin D Level, HgbA1C, Trileptal or Levetiracetam level has been done since 11/29/22. No labs were done for R11 as ordered in April 2023. R2's Care Plan, undated documents the problem: Seizure Disorder related to Traumatic Head Injury. The interventions for this care plan include Obtain and monitor lab/diagnostic work as ordered. Report results to MD (Medical Doctor) and follow up as indicated. On 9/19/23 at 8:35 AM V1, Administrator, stated they cannot find R11's lab results for her Keppra and Trileptal drug levels that were ordered to be done in April 2023. She stated they have reached out to their contracted lab to find out why it was missed. V1 stated R11 was being taken to the local hospital to have the labs drawn now. On 9/19/23 at 8:48 AM V2, Director of Nursing, stated R11 was on the lab's schedule on 4/6/23 to have labs drawn as ordered but it wasn't done. She stated if a resident refuses to have labs drawn, the lab techs usually put a note regarding they were unable to obtain due to the resident refusing, and then the labs are re-scheduled to try again on the next lab draw date. V2 stated she thinks the lab just missed it. The facility's policy, Laboratory Testing Incident Reporting revised in 01/2018 documents, Purpose: To outline responsibilities for reporting and review of incidents associated with laboratory testing as ordered by a resident's physician to safeguard the resident. Guidelines: The Nursing Department will ensure the timely adherence of physician's orders for laboratory testing. Definition: An inappropriate or incorrect collection or omission of a specimen; including transport time and storage (temperature) or failure of the laboratory provider to properly process and print the report in a timely manner. 1. Laboratory test errors may include: c. The laboratory service fails to collect a specimen for testing; f. Laboratory tests not performed within 24 hours of requested date.

Based on observation, and interview the facility failed to provide 80 square feet of floor space per resident bed for 62 of 64 residents ( R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R13, R14, R15, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R43, R44, R45, R46, R47, R48, R49, R50, R51,R52, R53, R54, R55, R56, R57, R58, F59, R60, R61, and R62) reviewed for room size requirements in the sample of 64. Findings include: On 9/17/2023 at 9:02 AM, V1, Administrator, stated there have not been any changes to any of the rooms since the last survey and she has a waiver for these rooms because they are less than 80 square feet. The facility has 33 two bed resident rooms that can be occupied by 2 residents. According to historical data, the room measurements for these rooms provide 76 square feet per bed. All of these rooms are certified for Medicaid. On 9/17/2023 at 2:02 PM, V8, Maintenance Man, measured the rooms and verified that (R2, R4, R6, R9, R15, R17, R18, R19, R20, R22, R24, R26, R28, R29, R30, R32, R33, R34, R35, R36, R37, R38, R41, R47, R51, R56, R58, F59, and R62) all reside on the A hall in resident rooms that are waivered. On 9/18/2023 at 2:42 PM, 29 residents were residing on the A hall (R2, R4, R6, R9, R15, R17, R18, R19, R20, R22, R24, R26, R28, R29, R30, R32, R33, R34, R35, R36, R37, R38, R41, R47, R51, R56, R58, F59, and R62) all of these beds are Medicaid certified and provide 75 square feet per bed. On 9/17/2023 at 9:33 AM, on the B Hall the following residents (R1, R3, R5, R7, R8, R10, R11, R13, R14, R21, R23, R25, R27, R31, R39, R40, R43, R44, R45, R46, R48, R49, R50, R52, R53, R54, R55, R57, R60, R61) were all residing on the B hall, all of these beds are Medicaid certified and provide 75 square feet per bed. On 9/17/2023 at 4:02 PM, V8, Maintenance Man measured the rooms and verified that (R1, R3, R5, R7, R8, R10, R11, R13, R14, R21, R23, R25, R27, R31, R39, R40, R43, R44, R45, R46, R48, R49, R50, R52, R53, R54, R55, R57, R60, R61) all reside on the B hall in resident rooms that are waivered. Observations made throughout the survey from 9/17/2023 through 9/18/18 demonstrate no concerns or complaints vocalized by residents in relation to waivered room size. On 9/7/2023 at 2:00 PM, during the group meeting R1, R8, R36, R44 and R45 residents voiced no complaints or concerns regarding room size. On 9/18/2023 at 3:35 PM, V1 stated they did not have a policy on room measurements.

Based on interview and record review, the facility failed to provide consecutive 8 hour Registered Nurse (RN) coverage in the facility. This has the potential to affect all 64 residents in the facility. Findings include: On 7/20/22 at 11:30 AM, the Nursing Working staffing schedule from January 1, 2022, through July 19, 2022 was reviewed with V2, Director of Nurses. The facility did not have consecutive 8-hour RN coverage for the following days: 1/19/22, 3/24/22, 3/28/22, 3/29/22, 4/1/22 through 4/18/22, 4/21/22, 4/25/22, 4/29/22, 4/30/22, 5/8/22, 5/27/22, 6/6/22, 6/10/22, 6/18/22, and 6/19/22. On 7/20/22 at 11:00 am V2, Director of Nurses (DON), stated she knows there were some issues with RN coverage as one RN left and came back. V2 stated she has only been employed at the facility for four months. V2 stated she has hired two RNs for evenings since she started. 7/21/22 at 9:45 AM V2 stated that they do not have a policy on staffing. V2 stated that they use the CMS guidelines. The Resident's Census and Conditions of Resident, CMS 672, dated 7/18/2022, documents that the facility has 64 residents living in the facility.

Based on observation, interview, and record review, the facility failed to properly label and store medication. This failure has the potential to affect all 64 residents living in the facility. Findings include: On 7/19/2022 at 8:14 AM the facility's medication room was inspected. The medication room contained the following medication: c1. A clear unlabeled bag of 53 dark pink pills. The clear bag had These are 50mg Benadryl not 25mg handwritten in red ink on the clear bag. On 7/19/2022 at 8:17 AM, V4, Licensed Practical Nurse (LPN), stated that she did not know what was in the bag. V4 stated that It's illegal and they (pills) are not supposed to be in there (bag). V4 stated that the medication was stock and used for everyone unless they have an allergy. On 7/19/2022 at 8:19 AM V5, LPN, stated that, The only thing we can do is fix our mistakes. 2. R19's open, unlabeled with open date, vial of [MEDICATION(S)] 100 units. On 7/19/2022 at 8:25 AM, V2, Director of Nursing (DON), stated that [MEDICATION(S)] is good for 28 days once open. V4 stated that this is why there is an open date. V2 stated that when a vial is opened the open date is placed on the vial. On 7/19/2022 at 8:27 AM, V5 verified that the medication was open and in use. 3. On 7/19/2022 at 11:08 AM, a medication pass was observed with V4, LPN. V4 administered R15's scheduled [MEDICATION(S)] 0.125mg from a foil located inside an unlabeled clear plastic bag. On 7/19/2022 at 11:09 AM, V4 stated that the clear plastic bag did not have a label on it. V4 stated that they (nurses) usually remove the label from the box and put it on the bag. The facility's Medication Storage policy, effective date 5/2022, states 5. Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. It also states 10. Facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received. Facility should ensure that no transfers between containers are performed by non-Pharmacy personnel. The Resident's Census and Conditions of Resident, CMS 672, dated 7/18/2022, documents that the facility has 64 residents living in the facility.

Based on observation, interview and record review, the Facility failed to document and receive prior approval from the dietician before utilizing substitutions. This failure has the potential to affect all 64 residents residing in the facility. Findings include: On 7/18/2022 at 11:00 AM, V9, Dietary Aid, was observed serving Pork Loin, Stuffing, Brussel Sprouts and Applesauce with cinnamon for lunch. The Facility's Diet Spreadsheet, Spring/Summer 2022 Week 4 documents that Pork Loin, Zucchini Cornbread Dressing Bake, Brussels Sprouts, and Banana Split Cake were on the menu to be served. On 7/19/2022 at 1:30 PM, V6, Kitchen Manager stated, We didn't have Zucchini, just stuffing and our Bananas were liquified, so I sent them back. On 7/20/2022, at 2:46 PM, V1, Administrator stated, If I had known they didn't have zucchini or bananas I would have gone to the store. We just talked about following the menu. I would expect them to follow it. At this time, V1 confirmed the menu listed above was for 7/18/2022 and the menu was not followed. On 7/21/2022 at 11:45 AM, V1 stated, She (V6) should call and get permission from the dietician prior to, and she did not. She knows that now. The Facility's Menu Substitution Form documents that on 7/18/2022 stuffing was substituted for the scheduled Zucchini Corn Bread Bake. The reason for the substitution was out of stock. The Form does not include the Applesauce being substituted for the Banana Split Cake. The Facility's undated policy Making Menu Substitutions documents, A log of substitutions must be kept on file, including what food items were substituted, the date, reason and what new food item was served. The Facility's CMS 672 dated 7/18/2022, documents that there are 64 residents residing in the facility.

Based on observation, interview and record review, the Facility failed to maintain a sanitary environment in the food storage, prep, and serving area. This failure has the potential to affect all 64 residents residing in the building. Findings include: On 7/18/2022, at 8:45 AM, the white air conditioning unit in the dry food storage area had a black substance covering the vent. V6, Kitchen Manager, stated, I don't know what that is. I will have the maintenance man clean it. On 7/18/2022 at 10:35 AM V9, Dietary Aid, was preparing the mechanical soft meat. This surveyor saw a blackish/brown bug, approximately one inch in length, with long antennas scurry across the floor in the kitchen near the steam table. V9, nonchalantly stated, Yeah, that's a roach. I see them off and on. Usually, they are dead because they spray for them. On 7/18/2022, at 10:45 AM, V6, stated, We are supposed to call the pest control company if we see them. On 7/19/2022 at 8:30 AM, V1, Administrator stated, The black stuff was a foam seal that was in there to keep the air conditioner from rattling. It had gotten wet and disintegrated. On 7/19/2022 at 10:00 AM, V10, Maintenance, stated, I know they had an issue yesterday in the kitchen. They saw a roach in the kitchen. At this time, there were 3 dead bugs on the floor in the social service office. V10 picked them all up, without a glove and verified that one was a roach. On 7/20/2022 at 3:45 PM, V11, Dietary Aid, stated, We don't have a specific cleaning schedule, we just all pitch in. I never noticed all that dust up there. Yes, that's where the clean dishes come out of the washer. The Facility's Kitchen Sanitation Manual dated 2/2022 documents, Cleaning Schedule Policy: There will be a written comprehensive cleaning schedule posted and monitored to maintain the cleanliness and sanitation of food service equipment. It continues to document, A cleaning schedule will be posted, and employees will initial and date tasks when completed. The Facility's CMS 672 dated 7/18/2022, documents that there are 64 residents residing in the facility.

Based on observation, and record review, the facility failed to provide 80 square feet of floor space per resident bed for 33 two-bed resident rooms for 60 of 62 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31,R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, R43, R45, R46, R48, R49, R50, R51, R52, R53, R54, R55, R56, R57, R58, R59, R60, R61, R62 and R63 ) reviewed for room sizes in the sample of 63. Findings include: 1. The facility has 33 two-bed resident rooms that can be occupied by 2 residents. According to historical data, the room measurements for these rooms provide 76 square feet per bed. All these rooms are certified for Medicaid beds. 2. R1, R8, R12, R14, R15, R17, R18, R20, R23, R26, R27, R30, R32, R34, R36, R37, R39, R40, R41, R42, R44, R45, R46, R47, R49, R52, R55, R58, R59, R61, and R63 reside in rooms XX-XYZ on the A-hall. 3. R2, R3, R4, R5, R6, R7, R9, R10, R11, R13, R16, R19, R21, R22, R24, R25, R28, R29, R31, R33, R35, R38, R43, R48, R50, R51, R53, R54, R56, R57, R60, and R62, reside in rooms YY-YZX on B hall. On 7/19/22 at 9:00 AM V1, Administrator, stated that he is aware of square footage of the rooms and stated that he always gets a tag for this. On 7/21/2022 at 11:15 AM facility room size policy was requested. The policy was not provided by the facility.

Based on observation, interview and record review the facility failed to provide effective pest control program so that the facility is free of pests. 1. On 7/18/22 at 10:30 AM R38 stated that she has had to kill multiple bugs in her room. R38 stated that she has squashed spiders and roaches in her room. 2. On 7/19/2022 from 1:30 PM to 2:00 PM multiple large blackish brown bugs approximately 1 inch in length with antennas was observed crawling on the floor. On 7/19/22 at 2:00 PM V2, Director of Nursing (DON) identified the bug as a roach. 3. On 7/21/2022 at 11:50 AM observed a large black bug running across the floor in the social service office. On 7/21/22 at 3:00 PM V10, Maintenance, stated that they do have an exterminator company that comes out monthly. V10 stated that the company was out last month but they only spray the entry points. When asked to clarify? V10 stated that the company only sprays the entrances to the building and other areas when identified. 4. On 7/18/2022 at 10:35 AM V9, Dietary Aid, was preparing food in the prep area. This surveyor saw a blackish/brown bug, approximately one inch in length, with long antennas scurry across the floor in the kitchen near the steam table. At this time, V9, nonchalantly stated, Yeah, that's a roach. I see them off and on. Usually, they are dead because they spray for them. On 7/18/2022, at 10:45 AM, V6, Dietary Manager, stated, We are supposed to call the pest control company if we see them. On 7/21/2022 at 10:45 AM, V10, Maintenance, stated, I have not done anything about the bugs because the pest control company is coming Tuesday. The Facility's Pest Control Policy dated 9/2018 documents, Purpose: To prevent or control insects and rodents from spreading disease. It continues to document, 10. The facility shall be kept in such condition and cleaning procedures used to prevent the harborage or feeding of insects or rodents. The Facility's CMS 672 dated 7/18/2022, documents that there are 64 residents residing in the facility.

Based on interview, and record review, the facility failed to provide 8 continuous hours of Registered Nurse (RN) coverage. This has the potential to affect all 62 residents living in the facility. Finding includes: On 08/24/21 at 02:35 PM, V2, Director of Nurses (DON), stated, I do keep 8 hours of RN coverage most days. On 8/25/21 at 8:45 AM, V2 stated, I only have one Registered Nurse and she has been on vacation. V2 stated the facility did not have 8 hours of RN coverage on 8/3/21, 8/6/21, 8/7/21, 8/8/21, 8/12/21, 8/16/21 - 8/24/21. On 8/25/21 at 8:45 AM, V1, Administer, stated, We have been trying to hire RN's, but we haven't been able to hire RN's, only LPN's. On 8/26/21 at 10:33 AM, V1, stated the facility does not have a policy on RN coverage they just follow Federal Regulation's. The facility working schedule, dated 7/30/21 - 8/26/21, fails to document an RN worked on 8/3/21, 8/6/21, 8/7/21,8/8/21,8/12/21, 8/16/21 - 8/24/21. The Resident's Census and Conditions of Residents, CMS 672, dated 8/23/2021, documents that the facility has 62 residents living in the facility.

Based on observation, interview, and record review, the facility failed to follow proper hand hygiene for 3 of 16 residents (R8, R29, R62) observed for infection control, and hand hygiene in the sample of 63. Findings include: 1. On 8/24/21, at 9:30 AM, V5, Certified Nursing Assistant (CNA), and V6 (CNA), were performing incontinent care for R8 after a bowel movement. V6 sprayed perineal wash on wet washcloths and handed them to V5 who cleansed R8's anal area, buttocks, scrotum area, and back of R8's legs. V5 did not remove her soiled gloves or perform hand hygiene after performing incontinent care. V5 continued to assist R8 in turning, repositioning, and applying clean linen pads under R8 using the same soiled gloves. On 8/25/21, at 1:10 PM, V10, Licensed Practical Nurse (LPN), stated, For performing hand hygiene when working with a resident, I would use hand sanitizer or wash my hands first, gather any supplies I may need, put my gloves on, take care of the resident, get rid of anything soiled items, take off my gloves and wash my hands. On 8/25/21, at 1:12 PM, V7, LPN stated, I use hand sanitizer or wash my hands first, put my gloves on, take care of my resident, remove gloves and wash my hands. On 8/25/21, at 2:15 PM, V2, Director of Nurses (DON) stated, I would expect the staff to wash their hands or use hand sanitizer before, after glove change, and after care of a resident. I would also expect staff to change their gloves if soiled and perform proper hand hygiene. R8's Care Plan dated 7/22/21 documented that R8 has an Activity of Daily Living (ADL) self-care deficit and has potential for impaired skin integrity related to incontinence and poor bed mobility. R8's Minimum Data Set (MDS), dated [DATE], indicated that R8 is severely cognitively impaired and is totally dependent on staff for all Activities of Daily Living (ADL). R8 is frequently incontinent of urine and stool. 2. On 8/25/21, at 11:44 AM, R29 was sitting on side of her bed with her wheelchair next to her. R29 was trying to get up herself when V10 saw her from the hallway and stepped in to help. V10 asked R29 if she wanted to use the restroom and R29 stated, I've already peed. V10 did not put gloves on prior to assisting R29 to her wheelchair and rolled up the soiled bed linen and left them on the bed. V11, CNA, entered the room. V11 did not put gloves on as she picked up the soiled linen off the bed. V11 carried the soiled linen to a dirty linen hamper in the hallway. V11 then assisted R62 from the hall to her bed without performing hand hygiene or donning gloves. 3. On 8/24/21 at 12:23 PM, V11 donned gloves and assisted R62 transfer to the toilet. V11 failed to perform hand hygiene first. The facility's Hand Hygiene/Handwashing policy, dated 1/10/18, documents, Examples of when to perform hand hygiene (either alcohol-based hand sanitizer or handwashing). It continues, Before and after having direct contact with a patient's intact skin. It continues, After contact with inanimate objects in the immediate vicinity of the patient. It continues, After glove removal.

Based on observation, interview, and record review, the facility failed to maintain a safe environment to prevent falls and provide safe transfer techniques to prevent accidents for 2 of 16 residents (R4, R5) reviewed for accidents in the sample of 63. Findings include: R5's Minimum Data Set (MDS), dated [DATE], documents that R5's cognition was intact. On 8/24/2021 at 9:30 AM R5 stated I fell recently and didn't get hurt. I went to the hospital, but I was ok. R5's Fall Risk Assessment, dated 2/23/2021, documents that she was not at risk for falls. R5's Nurse's Notes dated 5/6/2021 at 7:30 AM, documents that R5 fell and hit her nose, face on a chair in the TV room. The Note documented R5 was ambulating to the vending machine through a narrow walkway and tripped on a box. he Note documented R5 fell and hit her nose, face on a chair in the TV room. The Note documented Resident assessed for injuries, noted to have scratch under R (right) eye and scratch above L (left) eye, slightly reddened area on bridge of nose. Complaints of pain in/around nose. R5's Fall Interdisciplinary Note (IDT), dated 5/6/2021, documents, Summary of the fall: Resident was ambulating to vending machine through narrow walkway and tripped on a box. Root cause of fall: Resident tripped while ambulating in a crowded area. Intervention and care plan updated: Box removed, and chairs rearranged to make pathway wider. On 8/26/2021 at 10:00 AM, V2, Director of Nursing (DON), states I would expect walkways to be clear of debris. The facility's policy Fall Prevention Program, dated 11/21/2017, documents, To assure the safety of all residents in the facility, when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. The Policy documents The resident's environment will be kept clear of clutter which would affect ambulation and remove hazards. 2. R4's MDS, dated [DATE], documents R4 is severely cognitively impaired and is totally dependent on 2 staff members for transfers. On 8/23/21 at 11:15 AM, V4, Certified Nurse's Aide (CNA) was questioned on how R4 transfers. V4 stated, (R4) is a mechanical lift but she is so skinny two people can lift her. On 8/23/21 at 12:34 PM, V4 and V11 CNA transferred R4 to bed without the use of a mechanical lift. They both hooked their arms under R4's arms and lifted her using the gait belt. R4 was just hanging from her arm pits and none of her body weight was touching the floor during the transfer. R4's Care Plan, dated 8/23/21, documents, (R4) has ADLS (Activity of Daily Living) self-care performance deficit R/T (related to) hx (history) of (R) hip replacement, poor motivation, and requires assist with ADL tasks from staff. Dx (diagnosis). [CONDITION(S)], Dementia. Observed transfer with (R4) not bearing weight bilaterally, changed to (mechanical) lift. Updated 8/23/21 (mechanical) lift with 2 staff for all transfers. On 8/26/21 at 9:25 AM, V2, stated, The mechanical lift should have been used to transfer (R4).

Based on observation, and record review, the facility failed to provide 80 square feet of floor space per resident bed for 33 two-bed resident rooms for 60 of 62 residents (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31,R32, R33, R34, R35, R36, R37, R38, R39, R40, R41, R42, R43, R45, R46, R48, R49, R50, R51, R52, R53, R54, R55, R56, R57, R58, R59, R60, R61, R62 and R63 ) reviewed for room sizes in the sample of 63. Findings include: 1. The facility has 33 two-bed resident rooms that can be occupied by 2 residents. According to historical data, the room measurements for these rooms provide 76 square feet per bed. All these rooms are certified for Medicaid beds. 2. R2, R7, R8, R10, R11, R12, R14, R15, R18, R19, R21, R24, R26, R27, R31, R32, R35, R36, R39, R40, R42, R43, R45, R48, R50, R52, R53, R55, R59 and R63 reside in Rooms A1-A17 on the A-hall. 3. R1, R3, R4, R5, R6, R9, R13, R16, R20, R22, R23, R25, R28, R29, R30, R33, R34, R37, R38, R41, R46, R49, R51, R54, R56, R57, R58, R60, R61 and R62 reside in Rooms B1-B16 on B hall.

Based on observation, interview and record review, the facility failed to prevent and/or contain the COVID-19 by failing to wear appropriate PPE (personal protective equipment) and sanitize mobile multiuse equipment for 5 of 12 residents (R1, R2 R9-R12) reviewed for infection control in the sample of 12. Findings include: On 2/5/2021 at 9:16 AM, V2, Director of Nursing (DON), stated the Red Zone houses the COVID-19 positive residents. The Yellow Zone is for the Recovered residents and possibly exposed residents. On 2/5/2021 at 11:30 AM, V3, Licensed Practical Nurse (LPN), stated that the gowns should be changed prior to entering one resident room to another. V3 pointed to the sign on the wall on the COVID-19 positive unit (Red Zone) that documented that gowns should be changed after leaving one room and entering another. On 2/5/2021 at 11:56 AM, V4, LPN, brought the medication cart from the Yellow Zone through the barrier to the Red Zone (COVID Unit). V3 stated to V4, You cannot bring the medication cart on the COVID unit. V4 replied, Oh, yes I can. During V4's medication pass on the Red Zone, V4 wore the same gown from room to room. On 2/5/2021 at 11:58 AM, V4 entered R1's rooms to administer medication. Left room and did not change her gown. On 2/5/2021 at 11:59 AM, V4 entered R11's rooms to administer medication. Left room and did not change her gown. On 2/5/2021 at 12:08 PM, V4 entered R2's rooms to administer medication. Left room and did not change her gown. On 2/5/2021 at 12:13 PM, V4 entered R10's rooms to administer medication. Left room and did not change her gown. On 2/5/2021 at 12:19 PM, V4 entered R9's rooms to administer medication. Left room and did not change her gown. On 2/5/2021 at 12:41 PM, V4 pushed the medication cart from the Red Zone back to the yellow zone. V4 wiped down the computer on the cart, the top and sides of the cart with a sanitizing wipe. V4 did not wipe down the back of the cart or the wheels of the cart. On 2/5/2021 at 12:32 PM, V3, LPN, entered R12's room and assisted R12 onto the bedpan. V3 stated that she did not change her gown but only changed her gloves after assisting R12 with the bedpan then reentered the room with R12's food. On 2/5/2021 at 12:50 PM, V3 stated, I did say that you should change your gown between residents because you do not always know if you contaminated the gown. The facility's Infection Control- Interim policy addressing healthcare crisis related to Human [MEDICAL CONDITION], revised 1/19/21, documents, Green Zone Those residents without symptoms and who are not suspected to have COVID-19. This category also includes residents who have recovered from COVID-19 and meet CDC (Centers for Disease Control) criteria for removing transmission-based precautions. Red Zone Confirmed COVID-19 positive or symptomatic PUI (persons under investigation). It continues, Yellow Zone- Observation Area (optional if space allows) Residents with symptoms that are pending test results or who have symptoms but have had negative PCR (polymerase chain reaction) or rapid POC (point of care) testing. It further documents, May use the yellow zone to monitor new admissions and re-admissions for the 14 day quarantine period. The policy documents under PPE recommended when caring for a patient with known or suspected COVID-19 includes: Gowns Put on a clean isolation gown upon entry into the patient room or area. It continues, remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area.

Based on interview, observation and record review, the facility failed to provide correct Range of Motion (ROM) exercises that included all joints, failed to identify/assess limitations for 2 of 8 residents (R43, R14) reviewed for ROM exercises in a sample of 65. This failure resulted in a decline in ROM for R43 of lower extremities that the facility had not identified. Findings include: 1. The Minimum Data Set ((MDS) dated [DATE], documents R43 to have short/long term memory deficits, with severe cognitive impairment and requires extensive assist of one to two staff for transfers and mobility. The MDS identifies no limitations of ROM, but does document R43 receives active ROM 7 days a week. On 07/31/18 at 12:55pm, V5 and V7 entered R43's room to transfer R43 from the bed to chair. A sit to stand mechanical transfer was done with R43. R43 remained stooped over during the transfer and did not stand up straight as R43's knees remained bent. On 08/02/18 at 2:45pm, R43 was in bed. V15 Certified Nurse Aide (CNA) was asked if she did ROM on R43 and responded yes. V15 repositioned R43 on R43's back and lowered the head of bed. R43's legs remained bent. V15 completed Flexion/Extension of R43's left arm, but failed to do abduction/adduction, horizontal abduction/adduction, internal/external rotations or hyperextension of shoulder joint. V15 then did flexion/extension of left elbow joint, but failed to do supination/pronation. R43 was calm and cooperative. V15 then did flexion/extension and hyperextension of R43's left wrist, but failed to do ulnar/radial deviation or circumduction of the wrist joint. V15 did flexion/extension of R43's fingers, but failed to do abduction/adduction on each finger. V15 did only the abduction/adduction exercise for the thumb joint and failed to include flexion/extension or opposition. Knee and hip joint received only flexion/extension with no abduction/adduction, internal/external or hyperextension of the hip joint. R43 was unable to straighten knees out. V15 did dorsiflexion/planter flexion of the ankle joint, but failed to do inversion/eversion and only did flexion/extension of the toe joints failed to complete the abduction/adduction of R43's toes. On 08/02/18 at 2:50pm, V15 stated R43 has declined adding that R43 doesn't straighten out legs and they do a full body mechanical lift on R43 at times. There is no full assessment, including limitations in degrees in R43's Electronic Health Record Assessment section. The Care plan dated 06/05/18 documents R43 to have limited range of motion with a goal to be able to complete 2 repetitions of BUE/BLE (bilateral upper extremities/bilateral lower extremities) with interventions for staff to assess pain, encourage socialization during exercises, provide encouragement, and provide pain medication prior to exercise. The policy/procedure entitled Passive Range of Motion Exercises undated documents the policy as residents will receive passive range of motion exercises as the need indicates per the Functional Limitation in Range of Motion assessment or per physician order. The procedure documents residents will be assessed for their need of passive range of motion (PROM) per the Functional Limitation in Range of Motion assessment, If the resident is recommended for a PROM program, trained nursing staff will provide the range of motion exercises as outlined under ROM technique, and AROM is provided when the resident performs the movement and the staff provides instructions on range completion. The policy also documents PROM is provided by the staff with no assist from the resident. The policy continues to identify all planes for shoulder, elbow, wrist, fingers, hips, knees, ankles and toes with instructions for the staff on how to do them. 2. On 08/02/18 at 3:33 pm V21 Certified Nursing Assistant (CNA), conducted range of motion on R14. V21 conducted on shoulder joint flexion, extension, abduction, adduction and internal and external rotation, but failed horizontal abduction and adduction and hyperextension. Conducted on elbow, joint flexion and extension, but failed supination and pronation. V21 failed on wrist joint flexion, extension, hyperextension, ulnar, radial deviation and circumduction. Conducted on finger joint flexion and extension, but failed on abduction and adduction. V21 conducted on thumb joint opposition, but failed on thumb joint flexion, extension, adduction, and abduction. Conducted on hip joint flexion, extension, abduction, adduction failed on internal and external rotation and hyperextension. Conducted knee joint flexion and extension. Conducted ankle joint, dorsiflexion and plantar flexion, but failed inversion and eversion. V21 failed flexion, extension, abduction and adduction on toe joint. On 08/02/18 at 3:40 pm V14 stated, I need this every day. On 08/02/18 V21 stated, I think I got everything., I try to do 10 reps, if I have the time. It depends on the resident, but I conduct range of motion every other day. R14's Minimum Data Set ((MDS) dated [DATE] documents, R14 to be extensive/limited assistance with all ADL's (activities of daily living). R14's care plan dated 08/02/18 documents in part; (R14) has an ADL self-care performance deficit r/t (right) Limited Mobility, Pain to bilateral knees, Activity Intolerance.

Based on interview, observation and record review, the facility failed to identify, assess and monitor for [MEDICAL CONDITION] and urinary tract infections [MEDICAL CONDITION] for 1 of 1 resident, (R40) reviewed for urinary catheters in a sample of 65. This failure resulted in an emergency room visit for urinary obstruction and subsequent urinary catheter for R40. Findings include: 1. The Minimal Data Set ((MDS) dated [DATE] identifies R40 as having severe cognitive impairment with a Brief Interview of Mental status (BIMS) score of 6 and require minimal to supervision of one staff for activities of daily living. The Electronic Health Record (EHR) dated 07/01/18 at 6:56am has an entry by V13 Licensed Practical Nurse (LPN) in the progress notes that document Abdominal pain in response to his request for pain medication. The Medication Administration Record [REDACTED]. The progress notes fail to reflect any further assessment of R40's abdomen at the time of his complaints. On 07/01/18 at 9:36am, V14 Registered Nurse (RN) documented in the progress notes the pain medication was effective, but again, fails to reflect any assessment toward his previous abdominal pain. The EHR progress note entry dated 07/01/18 at 9:44am, documents Resident complained of not urinating in over 24 hours. (V13 - night shift nurse) reported to writer that R40 had told her that as well. RN told R40 to drink more water. Left note for MD. Again, there is no evidence that either nurse assessed R40's abdomen to determine a causative factor for complaints of abdominal pain or inability to void following this complaint. There is no documentation that the physician was notified of R40's complaints. The MAR indicated [REDACTED]. Again, there is no follow up on the effectiveness of this medication and no assessment toward his complaint of abdominal pain or whether he was voiding in appropriate amounts. On 07/02/18 at 1957 (7:57pm), V10 LPN documented CNA (certified Nurse Aide) to writer and reported that he had a small bowel movement and noted blood in the toilet. There was a small amount of bright red blood in the stool. Resident stated, he has been having gas, assessed resident, did not note any abnormalities r/t (related to) rectum area. Resident reported, he does have a hx (history) of hemorrhoids. Written phone MD's office . The is no evidence the nurse physically assessed R40 at the time. On 07/03/18 at 4:29pm, V17 saw R40 at the facility and documented, complains of a change in bowel habits and having a difficult time with a bowel movement. R40 has never had a colonoscopy and I strongly encouraged R40 to get one. We will see about making an appointment with Dr. V18. R40 seems to be reluctant. I'm not sure that R40 will do it. R40 also, says he's had some trouble with urinating, but a bladder scan post residual is basically unremarkable, so at this time I think we can observe. There is no evidence V17 was aware of his previous complaints of not urinating. The EHR progress notes have no further documentation toward R40's abdominal pain or monitoring until 7/8/18 at 19:59 (7:59pm,) when V8 RN documents Resident complained of abdominal discomfort and could not urinate except for little bits. At 1745 when R40 came up for meds (medications), stated R40 had been complaining and laying in R40's room. He ate supper, took meds and went to lay down. R40 came back up to see writer at 1915 stating stomach still hurting, penis was swollen and wanted to go to hospital, vital signs were 118/82, pulse 86, esp (respirations) 18 and temp 97.8. Nurse went with resident to resident's room and assessed resident. Penis was not swollen, but abdomen was firm and tender in lower quadrants and distended, writer could not hear bowel sounds except on sides towards back, notified Dr. V16 at 1945, who is on call for Dr V17 and he ordered for resident to be sent to (hospital) ER. Notified V2,( DON), of transfer and called ambulance, they arrived at 1955. There is no evidence V8 assessed R40 at the time of initial complaint at 1745 (5:45pm.) The EHR Progress notes dated 07/09/18 00:30 (12:30am), document Returned with new orders for Keflex and has a Foley, dx (diagnosis) [MEDICAL CONDITION]. Skin has no changes; He is in a pleasant mood. Hospital Emergency Discharge records dated, 07/08/18 documents R40's [DIAGNOSES REDACTED]. The report documented R40 returned with a urinary catheter and Keflex 500mg three times a day (TID) which was started on 07/09/18 per the (MONTH) MAR. On 07/17/2018, 14:18 (2:18pm), the EHR progress notes document Writer phoned (hospital) and requested (lab) be sent to facility, rec'd (received) and suggesting contamination, faxed to MD's office, also called the MD (medical doctor) office and left message to inquire about an end date, for Keflex or re-collection. On 07/17/18 15:14 (3:14pm), the EHR progress notes document Rec'd phone call from Dr. V17's office to discontinue ABT (antibiotic). On 07/31/18 at 13:01 (1:01pm) and at 11:29am, the progress notes document R40 received, [MEDICATION NAME] Tablet 650 MG for complaint of pain. On 07/31/18 at 9:51am, the progress notes document Rec'd phone call from Dr. Office, stating they need to change aptt. (Appointment) from this afternoon at 1330 pm to next Tuesday at 1330. On 07/31/18 at 11:45am, R40 ambulated independently down the hall to the nurse and asked for pain medication due to tube pointing to urinary catheter tubing. The tubing was extending, out over the waistband of jogging pants with the collection bag hooked on R40's walker bar. The urine in the tubing was cloudy white with a large amount of mucus and clumps in side. On 08/01/18 at 3:56pm, V2, Director of Nursing (DON) stated R40 was complaining of retention and was sent to the hospital the early part of (MONTH) where R40 had the catheter placed. V2 stated R40 returned to the facility with the catheter. V2 stated, R40 was supposed to have a follow up appointment this week but the Doctor's office called and rescheduled to next week. There is no documentation of R40's urine. V2 stated she would have expected, the nurses to physically assess R40 at the time of the complaint and to follow up to ensure R40 was voiding in sufficient amounts. V2 also stated she noted the physician was not notified which she would have expected them to do. The Treatment Administration Record (TAR) for (MONTH) and (MONTH) (YEAR) fail to document any change of urinary tubing and/or collection bag. On 08/03/18 at 6:16am, V13 LPN documented in the EHR progress notes Upon assessment I ascertained that R40's Foley needed changing, explained this to R40. R40 adamantly refused several times. Said this place was unsanitary and wouldn't allow it. Explained that I would form a sterile field, but R40 continues to refuse. On 08/03/18 at 12:20pm, R40 was ambulating toward the dining room. The urine in the catheter tubing was white, mucousy with clumps in it. R40 stated I'm not good. At 12:30pm, R13 stated she noted R40's urine earlier today, but haven't had time to do anything with it yet. The care plan dated 03/09/18 documents a prior concerns with [MEDICAL CONDITION] with a current concern of R40 being non-compliant and resistive to care related to catheter care. Interventions include: will be compliant with catheter care daily, educate R40 of possible negative outcomes r/t (related to) non-compliance, encourage R40 to be compliant with care, Have staff that is most compatible provide care, and leave R40 alone and re-approach later as needed. The care plan fails to address R40 threading catheter tubing over pants waistline. On 08/01/18, at 3:30pm, V2 stated she thought the Keflex was [MEDICATION NAME] for R40 and didn't realize problems were detected on 07/01/18 until after looking into it now. When asked about R40's urine being cloudy and clumpy, V2 stated she didn't think he had a UTI, at the time of his emergency room visit and was unaware of his urine being cloudy with large amount of sediments in it at the time. V2 confirmed that R40's appointment was changed and that documentation of an assessment was not in the clinical record. Was supposed to see the specialist yesterday and they called and rescheduled until next week. V2 stated R40 does have a tendency to have the tubing of the catheter over his waist band and it is documented in the nurse's notes. V2 was asked about V17's reference to residual urine on 07/03/18 during his visit and stated it was probably from his tests done in (MONTH) (YEAR). The facility's policy and procedure entitled Urinary Catheter care dated 11/28/12 document the purpose as to establish guidelines to reduce the risk of, or prevent, infections in resident with an indwelling catheter. The policy documents indwelling catheters may be secured to prevent trauma and tension, catheters shall be positioned to maintain a downhill flow of urine to prevent a back flow of urine into the bladder or tubing, during transfer, ambulation and body positioning, and changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infections, obstructions, or when the closed system is compromised.

Based on observation, record review and interview, the facility failed to maintain 4 resident bedrooms free of potential Thermal Burn Hazards for 7 of 7 residents (R1, R2, R3, R4, R5, R6 and R7) reviewed for safety hazards in the sample of 7. The failure resulted in an Immediate Jeopardy. While the Immediate Jeopardy was removed on 01/23/2014, the facility remains out of compliance at severity level two, while the facility continues to educate staff on heating equipment use and hazards. Findings include: 1. On 01/23/2014 at 10:00 AM, four resident bedrooms, Rooms B1, B7, B10, and B13, were observed to have portable heating units plugged into outlets and located in open areas of these rooms between the foot ends of the two beds and the opposite wall. These electric portable heating units extended at least two feet into the pathway areas of all 4 bedrooms. Between 10:05 AM to 10:12 AM temperatures of the surfaces of these four portable heating units were taken by placing heat sensitive test tapes, which turn black when temperatures exceed 140 degrees Fahrenheit (F), on accessible surfaces of the units. These test tapes turned black instantly for all four heating units demonstrating that their surface temperatures were above 140 degrees F. 2. The residents residing in these four bedrooms at the time were R1, R2, R3, R4, R5, R6 and R7. The Minimum Data Set (MDS) of the following residents documented "Activities of Daily Living (ADL) Assistance" in regard to "how a resident walks between locations in his/her room". R2 and R4 - "Limited Assistance" meaning "resident highly involved in activity; staff provide guided maneuvering of limbs or non-weight bearing assistance" dated 12/30/2013 for R2 and 11/29/13 for R4. The MDS of the following residents documented "Functional Status" assessments in regard to "Balance During Transitions and Walking": R1 - "Not steady, only able to stabilize with staff assistance" when "moving from seated to standing position" dated 11/26/2013. R2, R4 and R7 - "Not steady, only able to stabilize with staff assistance" when "walking" dated 12/30/2013 for R2, 11/29/13 for R4, and 12/27/2013 for R7. The Fall Risk Assessments for the following residents documented fall risk scores (a rating of 10 or above is considered "AT RISK"): R1 - score of 13, dated 11/20/2013; R2 - score of 13, dated 01/16/2014; and R4 - score of 10, dated 11/25/2013. The facility's Accident and Incident Log documents that R2 had falls on 11/07/2013, 11/17/2013 and 12/10/2013. The log documents that R2 tripped over a peer's wheelchair for the 12/10/2013 incident. R2's Nurse's Notes document that on 11/07/2013, R2 explained her fall by saying "she tripped over the bedspread." For the 11/17/2013 fall, R2's Nurse's Notes document that R2 said, "I got up from my chair turned to talk to resident and fell down." On 01/28/2014, at 11:30 AM, E4 (MDS Coordinator) stated during interview that R1 is considered to have a 'Moderately Impaired Cognition' at this time and that R2's cognition level is considered to be of 'Modified Independence' in regard to the Staff Assessment for Mental Status portion of the MDS. 3. On 01/23/2014 at 10:30 AM, E1 stated that she started as Administrator on 01/07/2014, and the portable heaters were already in place at that time. On 01/23/2014 at 10:35 AM, E2 stated that there are 7 residents in these rooms and there have been no incidents or injuries related to these portable heating units. On 01/23/2014 at 10:45 AM, E3 stated that the use of the portable heaters were put in place on December 26, 2013 due to the breakers station on B hall being vulnerable to overheating and tripping the power out. To remedy this temporarily, E3 had Z1 (electrical contractor) re-route the electrical system within the B hall station temporarily until the complete repair could be done. E3 stated the re-routing made it "necessary" to turn off the wall heating units in these four bedrooms and replace them with portable units until the repairs could be done. E3 stated the timing of the repair is unknown because the part needed is not available to be shipped according to Z1. 4. The Immediate Jeopardy was identified and determined to have begun on 01/23/2014 at 10:12 AM when the 4 portable heaters were observed with surface temperatures exceeding 140 Degrees F. E1 (Administrator), E2 (Director of Nurses), and E3 (Maintenance) were notified of the Immediate Jeopardy on 1/23/14 at 2:05 PM. 5. Based on observation and record review the facility took the following actions to remove the immediacy: a.) On 01/23/2013 at 2:10 PM, the portable heating units were removed from the 4 resident bedrooms, and placed in storage in E1's office. b.) On 1/23/14 at 3:10 PM, the facility had R1 - R7 discharged , and in transport to another facility due to the four bedrooms being without heat. c.) On 1/23/14, the facility provided a plan to insure the unheated bedrooms which had water/sprinkler pipes had some means of getting enough heat to the pipes to prevent them from freezing. d.) From 1/24 to 1/26/14, the facility in-serviced all staff about surface heat hazards.